Years of hospital bed closures and policy changes have already seen a significant shift of patients from hospital to community settings.

Sue McLaughlin, Interim Deputy Director of Nursing for Patient Safety and Quality at Berkshire Healthcare NHS Foundation Trust, says the changes recommended in the review of the Mental Health Act give much greater legal weight to people's wishes and preferences, and the need to require stronger, transparent justification for using compulsory powers is positive. "However, we need to ensure the community structures exist alongside this to support people with recovery-focused approaches, especially when the threshold for secondary care services is not met, to avoid deteriorating mental health."


McLaughlin is concerned that without resources to enable a focus on early intervention and preventive strategies in the community, people will continue to look to hospital admissions due to a lack of alternatives. "Advance refusals of treatment, such as ECT, and the ability to nominate a relative to make decisions are welcome, but will require robust infrastructure to enable these conversations to take place at the right time and with support."

She wants more resources to enable trusts to deliver services in line with best practice and NICE guidance, together with more effective use of non-clinical/ medical modes of support.

"People with complex physical and mental health needs should always have help available to plan and co-ordinate their care and also ensure timely access to the appropriate care or treatment options and services, whatever they may be. However, it isn't always a clinical or medical intervention that is required. A narrow focus on only clinical outcomes is likely to be detrimental and much more effort is required to find out what outcomes matter most to individuals. Utilising quality improvement approaches so that those closest to the problem (staff and patients) can devise the best solutions and implement them, agreeing outcomes collaboratively, can help.

"For good mental health, people need the basics but also a sense of connection to their community. This is not always achievable in the current climate, and more attention and relocation of resource is needed to enable a focus on this. 

"Service providers also need to connect to work collaboratively, and this can be hindered at times if we are constantly relocating and retendering. A balance needs to be achieved between cost and quality. Effort needs to be allocated to these relationships across sectors at all levels."

Embracing new technologies to connect with people is also important. Electronic health records and telehealth support that are accessible to commissioners, providers and patients will have a huge impact if used to the full potential. "New technology can assist with monitoring and care co-ordination at scale, remove duplication and will reap benefits for all those receiving and providing care."

Dr Tony Romero is the Chief Executive Officer at Cygnet Health Care, which cares for around 3,000 adults and young people with mental illness, learning difficulties and other disorders in secure and community settings.


Romero feels the need for more clarity about how Deprivation of Liberty Safeguards (DoLS) will impact – especially for elderly people and those with learning disabilities who are moving into community settings.

"Even if the Mental Health Act does not apply to you, restrictions on freedom of choice do. If you have learning difficulties, I may not be able to detain you under the Act, but I could do so under DoLS if my assessment is that you don't have capacity. This means we go from detaining people in hospital to 'detaining' them in care homes under DoLS, with fewer safety mechanisms and appeals processes."

Romero's concerns become even more valid, as DoLS is due to be replaced by the new Liberty Protection Safeguards (LPS) in October 2020, with arguably even fewer safeguards than under the current DoLS regime, and with a much broader application to patients in any setting.

Romero calls for care services to ensure staff are fully trained in carrying out capacity assessments. "We train our staff on evaluation and try to be as least restrictive as possible, but that does not mean that in a country where 40,000-50,000 people might be affected, we don't sometimes get it wrong."

He is concerned that the closure of learning disability beds might create a 'revolving door' pressure on inpatient psychiatric beds, where a patient is in crisis and there is no option but detention. To prevent this, he feels that people with learning disabilities need specialised community psychologists, and speech and language therapists. "If they don't get these services, they will be prompt to relapse. Running such complex services will rely heavily on the third sector, charities and the private for-profit and not-for-profit sector."

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